FORM ‘F’ [See Sub-rule (1) of Rule 6] Nomination To (Give here name or description of the establishment with full address) 1, Shri/Shrimati ____________________________ (Name in full here) Whose particulars are given in the statement below, hereby nominate the person(s) mentioned below to receive the gratuity payable after my death as also the gratuity standing to my credit in the event of my death before that amount has become payable, or having become payable has not been paid and direct that the said amount of gratuity shall be paid in proportion indicated against the name(s) of the nominee(s). 2.I hereby certify that the person(s) nominated is a /are member(s) of my family with meaning of clause(h) of Section 2 of the Payment of Gratuity Act, 1972. 3. I hereby declare that I have no family with in the meaning of clause (h) of section 2 of the said Act. 4.[a] My father/mother/parents is/are not dependent on me. [b] My husband’s father/mother/parents is/are not dependent on my husband. 5. I have excluded my husband from my family by a notice dated the ________ to the controlling authority in terms of the proviso to clause (h) of Section 2 of the said Act. 6.Nomination made herein invalidates my previous nominations Nominee(s) Name in full with full Relationship Age of Address of nominees(s) with the employee shared  1. 2. 3.  
Proportion by which the gratuity will be
Statement 1. 2. 3. 4. 5. 6. 7. 8. Name of employer in full Sex Religion Whether unmarried/married/widow/widower Department / Branch / Section where employed Post held with Ticket, or Serial No. if any Date of appointment Permanent Address
Village Thana.. Sub-division. Post Office.. District State ____________________________________________________________
___________ Place : Date :
Signature/Thumb,impression Of the Employee Declaration by Witnesses
Nomination signed / thumb-impressed before me. Name in full and full address of…….. 1. 2. Place : Date :...